Exploration of support to nurses working in the tuberculosis programme in the primary health care facilities by management in the Matlosana sub–district

Exploration of support to nurses working in the

Tuberculosis programme in the primary health

care facilities by management in the

Matlosana sub-district

Nelisa Ayanda Sekatane

N.Dip (VUT) and B Cur (NWU)

Dissertation submitted in accordance with the requirements for the degree of

MAGISTER CURATIONIS (Nursing Management)

in the school of

NURSING SCIENCES

at the

NORTH-WEST UNIVERSITY (POTCHEFSTROOM CAMPUS)

Supervisor:

Dr. Deliwe Rene Phetlhu

Co-supervisor:

Mrs. Gedina E. de Wet

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SUMMARY

Tuberculosis is a health threat, globally, in Africa, South Africa as well as in the North West Province. Although a number of positive interventions have been implemented, like the introduction of direct observation treatment strategy, still tuberculosis remains a threat. This may be due to the fact that while interventions to fight tuberculosis have been formulated and implemented, the most important resource in the Department of Health, which are nurses. Nurses working in the tuberculosis programme who play a vital role in the implementation of the health strategy are left behind and not given the proper support that they need to ensure the implementation of the health strategy. Nurses need to receive physical, emotional and social support from management so that they can give quality care to their patients.

The purpose of this study was to explore the support from management to nurses working in the tuberculosis programme in the primary health care facilities at the Matlosana sub-district so as to make recommendations to management with the aim of improving the nurses’ work life and consequently rendering quality care to the tuberculosis patients.

The research was conducted in the Matlosana sub-district in the North West Province of South Africa. A qualitative research design was used to explore and describe the support by management to nurses working in the tuberculosis programme in the primary health care facilities. A purposive voluntary sampling method was used to select participants who met the set criteria. In depth Semi structured interviews were conducted. Data was captured on an audio recorder, and transcribed verbatim. The researcher and the co-coder analysed the data after data saturation was reached. A consensus was reached on the categories that emerged.

The results showed that most facility managers lack knowledge about tuberculosis making it difficult for them to support nurses working in the tuberculosis programme. The lack of support resulted in the arousal of feelings such as frustration, feeling undermined, feeling unnoticed and unappreciated. It also resulted in resistant behaviours such as underperformance, loss of interest in their work, wanting to leave to where they will be supported and reluctance to take annual leave due to fear of piling work. However, few participants reported supportive experiences from both their facility managers and from the tuberculosis coordinator.

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Recommendations were made for the field of nursing education, community health nursing practice and nursing research with the aim of improving the nurses’ work life and consequently rendering quality care to the tuberculosis patients.

Key concepts: Management, Tuberculosis coordinator, Facility managers, Tuberculosis, nurses, support, primary health care facilities, Tuberculosis programme.

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OPSOMMING

Tuberkulose is ’n gesondheidsrisiko, internasionaal, in Afrika, Suid-Afrika sowel as in die Noordwes Provinsie. Nieteenstaande die feit dat ’n aantal positiewe intervensies reeds geïmplementeer is, soos byvoorbeeld die instelling van direkte observasie-behandelingstrategieë, bly tuberkulose ’n wesenlike bedreiging. Dit kan moontlik toegeskryf word aan die feit dat terwyl intervensies om tuberkulose te beveg geformuleer en geïmplementeer word, die nodige ondersteuning nie aan een van die mees belangrike skakels en hulpbronne van die Departement van Gesondheid genoegsaam is nie, naamlik die verpleegpersoneel. Verpleegpersoneel speel ’n integrale rol in die implementering van die gesondheidstrategie teen tuberkulose, en hulle behoort fisiese, emosionele en sosiale ondersteuning van bestuur te ontvang om sodoende op nuwe en innoverende wyses kwaliteit hulp aan hul pasiënte te kan bied. Sonder hierdie ondersteuning word verpleegpersoneel geïnhibeerd gelaat omdat hulle onbevoeg, ongewaardeerd en onseker voel. Hulle het nie die nodige selfvertroue om kwaliteit ondersteuning aan hul tuberkulose pasiënte te lewer nie.

Teen hierdie agtergrond word die doel van die studie dus geformuleer as die ondersoek na ondersteuning van bestuurskant, asook die ondersteuningsbehoeftes van die verpleegsters wat werksaam is in die tuberkulose programme van die primêre gesondheidsfasiliteite in die Matlosana sub-distrik van die Noordwes Provinsie. Sodoende kan daar aanbevelings gemaak word aan bestuur om die kwaliteit van ondersteuning aan verpleegpersoneel te verbeter met die gevolg dat ondersteuning aan tuberkulose pasiënte sal verbeter.

Die navorsing is gedoen in die Matlosana sub-distrik van die Noordwes Provinsie in Suid-Afrika. ’n Kwalitatiewe navorsingsontwerp is gebruik om die ondersteuning van bestuur en die ondersteuningsbehoeftes van die verpleegpersoneel te bepaal in die tuberkulose programme van die primêre gesondheidsorgfasiliteite. Gevolglik was dit nodig om ’n doelgerigte vrywillige steekproef metode te gebruik om respondente wat aan die nodige kriteria voldoen, te identifiseer. In diepte semi-gestruktureerde onderhoude is gedoen en opgeneem waarna dit verbatim getranskribeer is. Die navorser en kodeerder het die data gekodeer en ontleed. Die data-analise is gestaak nadat ’n data-versadigingspunt bereik is waar konsensus aangaande die geïdentifiseerde kriteria bereik is.

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Vanuit die resultate word die gevolgtrekking gemaak dat die verpleegsters bestuur se ondersteuning in die primêre tuberkulose programme as onvoldoende ervaar. Die resultate toon verder dat die meeste fasiliteitsbestuurders ’n tekort aan kennis van tuberkulose het, wat dit verder moeilik maak om die verpleegpersoneel te ondersteun. Verpleegpersoneel het aangetoon dat hulle die behoefte na persoonlike ondersteuning waar bestuur gesprek voer met hulle oor hul doen en late, terwyl ander aangetoon het dat hul graag erkenning en aansporings sou wou ontvang van bestuur. Hierdie gebrek aan ondersteuning lei tot gevoelens soos frustrasie, ondermyning, onsigbaarheid in die werkplek en ook ongewaardeerdheid. Verder word aangetoon dat hierdie gevoelens lei tot weerstandige werksgedrag soos onderprestasie, verlies aan belangstelling in die werk, moontlike bedankings en dat daar nie jaarliks verlof geneem word nie omdat die werk net ophoop in hul afwesigheid. Daar is egter ook ervarings van positiewe ondersteuning gedokumenteer deur beide verpleegsters en fasiliteitsbestuurders.

Aanbevelings word gemaak in die dissiplines van verpleegopleiding, gemeenskapsgesondheid en verpleegpersoneelpraktyk wen ook verpleegkundige navorsing. Die aanbevelings is gemik daarop om verpleegpersoneel se werksomstandighede te verbeter asook om konstant verbeterde kwaliteit ondersteuning aan teringpasiënte te lewer.

Kernbegrippe: Bestuur, tuberkulose koördineerder, fasiliteitsbestuurder, tuberkulose, verpleegpersoneel, ondersteuning, primere gesondheidfasiliteite, tuberkulose programme.

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DEDICATION

This study is dedicated to all the nurses working in the tuberculosis programme at the primary health care facilities, those who have been entrusted with the lives of the poverty stricken tuberculosis patients and those huge tuberculosis records which they are to daily update for a period of 6-9 months, even 10 months depending on the type of tuberculosis. I will forever be grateful to them for their readiness to participate in this study forming a voice for all the nurses, especially those working in the tuberculosis programme at the primary health care facilities.

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ACKNOWLEDGEMENTS

This dissertation would have but remained a dream had it not been for the guidance and the help of numerous individuals who in many ways contributed and extended their valuable assistance in the preparation and completion of this study.

 First and foremost, my utmost gratitude to my supervisor Dr. Deliwe René Phetlhu, Head of the Nursing Department at the North-West University (Mafikeng Campus) whose unselfish and unfailing support, sincerity and encouragement I will never forget. Dr. Phetlhu has been my inspiration as I overcame all the obstacles in the completion this research work.

 Mrs de Wet, Senior lecturer at the North-West University (Potchefstroom campus) co- supervisor to Dr Phetlhu, who had kind concern and consideration regarding my academic requirements.

 Mrs Evelyn Nkhumane, thank you for your unselfish and unfailing support as my co-coder.  Mrs Antoinette Bisschoff, I will forever be grateful to you, for you were always available as

my editor even when you were admitted in the hospital, thank you for;

o assisting me with the language control;

o for assisting me with the editing of the bibliography;

o re-editing the electronic version of this dissertation for consistent pagination prior to printing of the required number of hard copies; and for

o helping out in sorting and compilation of the printed copies and thank you for translating my summary to Afrikaans.

 Mbulelo Dala (Town and Regional Planner of the Matlosana City Council) for the insights he shared on the demographic and geographical information of the Matlosana City Council.

 North West Department of Health for granting me the permission to do this study in their Province.

 Mrs Motala (sub district manager of the Matlosana health services) of the Matlosana sub district for granting me the permission to do this study in their area.

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 I praise God for my father and mother (Neo & Nanziwe), not forgetting my new parents (Thomas and Margaret). Thank you for your support and prayers. You are the best parents!

 I am filled with gratitude when I think about all the nurses working in the tuberculosis programme at the Primary health facilities in all the 16 clinics who participated in this study: you did it.

 I want to give thanks to my local area manager Regina Mvundle and my facility manager Queen Molefi not forgetting my friends and colleagues at the Botshabelo Community Health Centre in Khuma for your love, understanding and support; you are my family. May God bless you all.

 I also thank all the brothers and sisters not mentioned here, especially in the: o Sekatane & the Monyatsi family, for your support and prayers.

o My Husband, Sello, you have been nothing but a solid rock to lean and a shoulder to cry on during my trying times. Thank you very much, God bless you.

 Last but not least, to the one above all of us, my heavenly Father, God almighty, the omnipresent God, for answering my prayers for enabling me to undertake this study, for giving me the strength to plod on despite my constitution of wanting to give up and throw in the towel and for making it possible for the above mentioned people and institutions to help me in the way they did. Thank you my dear Father for it is all because of you. Indeed like the apostle Paul I know how to say, “I can do all things through Christ who gives me strength “(Philippians 4:13).

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TABLE OF CONTENTS

LIST OF ADDENDUMS xii

LIST OF TABLES xiii

LIST OF ABBREVIATIONS xiv

CHAPTER 1: OVERVIEW OF THE STUDY 1 1.1 INTRODUCTION AND BACKGROUND 1

1.2 PROBLEM STATEMENT 6

1.3 AIM AND OBJECTIVES OF THE STUDY 6

1.4 RESEARCH QUESTIONS 7

1.5 SIGNIFICANCE OF THE STUDY 7 1.6 THEORETICAL ASSUMPTION 7 1.6.1 Central theoretical argument 8 1.6.2 Conceptual definitions 8 1.6.2.1 Support 8 1.6.2.2 Tuberculosis (TB) 8 1.6.2.3 Tuberculosis programme 9 1.6.2.4 Nurse 9 1.6.2.5 Management 9 1.6.2.6 Facility Manager 10 1.6.2.7 TB co-ordinator 10

1.6.2.8 Primary Health Care facility 10 1.7 RESEARCH DESIGN AND METHOD 11

1.7.1 Research design 11

1.7.1.1 Qualitative research 11 1.7.1.2 Exploratory design 11 1.7.1.3 Descriptive design 12 1.7.1.4 Contextual design 12

x 1.7.2 Research method 12 1.7.2.1 Population 13 1.7.2.2 Sampling 13 1.7.2.3 Study context 14 1.7.2.4 Data collection 14 1.7.2.5 Data analysis 15 1.7.2.6 Literature control 16 1.8 TRUSTWORTHINESS 16 1.8.1 Truth value 16 1.8.2 Applicability 16 1.8.3 Consistency 17 1.8.4 Neutrality 17 1.9 ETHICAL ASPECTS 18

1.9.1 Review by ethical committee 18 1.9.2 Fundamental ethical principles 18

1.10 CHAPTER OUTLINE 21

1.11 CONCLUSION 21

CHAPTER 2: RESEARCH METHODOLOGY 22

2.1 INTRODUCTION 22

2.2 RESEARCH DESIGN AND METHOD 22

2.2.1 Research design 22 2.2.1.1 Qualitative research 22 2.2.2 Research Method 24 2.2.2.1 Population 24 2.2.2.2 Sampling 24 2.2.2.3 Study Context 25 2.2.2.4 Data collection 26 2.2.2.5 Data analysis 30 2.2.2.6 Literature Control 31 2.3 TRUSTWORTHINESS 32 2.3.1 Truth-value 32 2.3.2 Applicability 33 2.3.3 Consistency 33 2.3.4 Neutrality 34

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2.4 ETHICAL ASPECTS 34

2.4.1 Review by ethical committee 34 2.4.2 Fundamental ethical principles 35 2.4.2.1 The right to self-determination 35 2.4.2.2 The right to full disclosure 35 2.4.2.3 The right to privacy, anonymity and confidentiality 36 2.4.2.4. Scientific honesty 37

2.5 CONCLUSION 37

CHAPTER 3: RESEARCH FINDINGS AND LITERATURE CONTROL

3.1 INTRODUCTION 38

3.2 FINDINGS AND RELATED DISCUSSIONS 38 3.2.1 Findings pertaining to nurses’ demographics 38 3.2.2 Discussion of findings pertaining to nurses’ demographics 39 3.2.3 Findings and discussion pertaining to identified themes 40 3.2.3.1 The nurses’ perceptions of support by management 42 3.2.3.2 The nurses’ needs with regard to support 54 3.3 CONCLUSIONS 59

CHAPTER 4: CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS FOR NURSING EDUCATION, NURSING RESEARCH AND COMMUNITY HEALTH PRACTICE

4.1 INTRODUCTION 60

4.2 CONCLUSIONS 60

4.2.1 Nurses’ perception of support by management 61 4.2.2 The nurses’ needs with regard to support by management 62 4.3 LIMITATIONS OF THE STUDY 63 4.4 RECOMMENDATIONS FOR NURSING EDUCATION, NURSING

RESEARCH AND COMMUNITY HEALTH NURSING PRACTICE 64 4.4.1 Recommendations for nursing education 64 4.4.2 Recommendations for nursing research 64 4.4.3 Recommendations for community health nursing practice 65

4.5 SUMMARY 65

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LIST OF ADDENDUMS

A: Requisition letter to the Provincial North West Department of Health

(NWDoH) 80

B: Requisition letter to the Dr Kenneth Kaunda District & Matlosana sub

district NW 82

C: NWDoH ethical approval letter 84 D: Dr Kenneth Kaunda District & Matlosana Sub-district Approval letter 87 E: Demographic questionnaire 88

F: Consent Form 90

G: Transcribed Scripts 93

H: Field notes 98

I: Researcher’s memo 104 J: Semi structured interview Schedule 105 K: Declaration by language editor 106

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LIST OF TABLES

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LIST OF ABBREVIATIONS

DOTS: Directly Observed Treatment Strategy

EN: Enrolled nurse

ENA: Enrolled nurse assistant

HIV: Human immune deficiency virus

AIDS: Acquired immune deficiency syndrome

MDGs: Millennium development goals

MDR: Multidrug resistant

NWU: North-West University

PHC: Primary Health Care

PROF NURSE: Professional Nurse

SANC: South African Nursing Council

TB: Tuberculosis

UN: United Nations

WHO: World Health Organisation

XDR: Extensively drug resistant

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CHAPTER 1

OVERVIEW OF THE STUDY

1.1 INTRODUCTION AND BACKGROUND

Tuberculosis (TB) is one of humanity’s greatest killers and it is out of control in many parts of the world. It is said to be the major constraint to economic development, since most TB deaths are among adults of working age (Vlok, 2006:515). Worldwide, there are 8 million new cases of TB each year and 3 million deaths, and every second someone in the world is newly infected with TB. One-third of the world's population is currently infected with TB and nearly three million people die from TB every year (World Health Organization, 2005a:104). In 2005 alone 1.6 million deaths resulted from TB making it to be the second only to HIV/AIDS as a cause of illness and death of adults. The annual number of new TB cases has quadrupled since 1990 and the number is continuing to rise across the African continent, killing more than half a million people every year (World Health Organization, 2005a:104).

Although it has only 11% of the world's population, Africa accounts today for more than a quarter of a million people every year infected with TB. There is an estimated 2.4 million TB cases and 540 000 TB deaths annually in Africa (World Health Organization, 2005a:1). South Africa, as part of Africa, is also experiencing this epidemic as it is one of 22 high-burdened TB countries and has the fifth highest number of notified TB cases in the world (Almeleh et al., 2006:77). Annually, the numbers have quadrupled from 61 486 in 1988 to 279 260 in 2004. On his “experts call for action on TB” speech, Hussey (2005) reported that there are about 250 000 new cases of TB every year in South Africa, and that number is growing.

The Matlosana sub-district in North-West Province also experiences the same trend with 6 642 new TB cases in 2007 alone. Matlosana sub-district is situated close to the Vaal River and it is dominated by mines, thus attracting a large number of people from all over South Africa including people from the neighbouring countries. Matlosana municipal area comprises a total area of 3 162 km² and is located in the south-eastern part of the North-West Province. The municipality covers the central part of the Dr. Kenneth Kaunda District Municipality area and consists of four towns namely Klerksdorp, Stilfontein, Orkney and Hartbeesfontein. Matlosana is bordered by Tlokwe (Potchefstroom) municipality area in the east; Maquassi Hills (Wolmaransstad) municipal area in

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the west; Ventersdorp local municipality in the north-east and the Free State Province in the south. Matlosana municipality area is also situated on the N12 Treasure Corridor which is a major route that connects cities like Johannesburg and Cape Town (City of Matlosana, 2009).

According to the (World Health Organization, 2003:11) poverty and the widening gap between the rich and the poor is one of the reasons for the global TB burden in various populations. To add to her speech, Tshabalala-Msimang (2006) said in her statement that “TB is one of the poverty-related challenges which include poor nutrition and inadequate housing”. In addition, the growing HIV problem also feeds directly into the spread of tuberculosis. Because of their lowered immunity people with HIV are 800 times more likely than the general population to acquire TB (Allender et al., 2010:232) (Amref, 2013). Furthermore, up to 40% of South African TB patients are co-infected with HIV and as a result the interaction between HIV and TB has enabled the HIV epidemic to contribute to a further increase in TB incidence.

Due to the high prevalence of TB incidents, the United Nations (UN) highlighted TB control and management as one of their Millennium Development Goals (MDGs) with the intention to halve its prevalence and mortality rate (Baltussen et al., 2005:331). Based on the MDGs, management intervention strategies such as the Directly Observed Treatment Strategy (DOTS) were identified and recommended, and South Africa as part of the UN adopted it in their own TB control programme. Despite all the possible interventions outlined by the World Health Organisation (WHO), the number of TB cases remains high and South Africa still continue to face one of the worst TB epidemics in the world, with people dying every day (Vlok, 2006:515; De Lange, 2006:3).

Incidentally, poor programme management is also mentioned as another reason for the increase of TB, and this is marked by the global emergence of Multi drug resistant (MDR-TB) and extensively drug resistance(XDR-TB), which according to the author are stark reminders of the failure of public health systems to control TB (Reuter, 2007:10). Not only is the programme management a problem but the issue of poor programme management is further compounded by a shortage of nurses with more and more nurses leaving the country for greener pastures.

Nurses are at the forefront of TB prevention, care and treatment; hence, nursing competence in the detection, control and care is crucial. Nurses working in a TB programme in a Primary Health Care (PHC) facility carry the bulk of work in TB prevention, care and treatment (Ghebrehiwet, 2006:239). Unlike the expectations placed on a nurse in the hospital who are not involved with the TB patients, nurses in the TB programme in PHC facilities have the added responsibility, not only to the individual but to all who comes into contact with them as nurses, like family, and the community.

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The nurse in the TB programme is expected to play the following roles and perform the following functions over and above what their colleagues who are not involved in TB care and management are exposed to:

 Advocacy;  Case detection;

 Initiation, administering and monitoring drug regimens;  Training of community health workers;

 Referrals and follow-ups of TB patients;

 Informing the patient of his/her diagnosis, nature, symptoms, complications and treatment of Tuberculosis;

 Reassure and encourage the patient in order to allay fear and get his cooperation in therapy;

 Inform the family and the patient’s employer to get their co-operation;

 Assess the patient and his/her environment and in consultation with the patient choose a suitable therapy regimen with which the patient is likely to comply;

 Request tests of sensitivity of tubercle bacillus to anti-TB drugs when submitting sputum for bacteriological investigation;

 Tracing of non compliant patients and conducting home visits for the very ill patients;

 Keeping of records yearly to state how many patients received primary treatment, where cured, died and defaulted through either non-compliance and absenteeism; and

 Administrative duties such as compiling monthly Tuberculosis statistics for the health information system (Vlok, 2006:536).

All these roles and functions create great challenges for the nurses hence they almost always experience work overload. This is also fuelled by factors such as a shortage of staff, poor working conditions, lack of trained nurses and a lack of knowledge of what the programme entails. These aspects often lead to nurses not being keen to work in the TB programmes in the PHC facilities.

Shortage of staff contributes to increased workload since those present are left to handle huge amounts of work alone (Emmanuelle & Mickey, 2008:2). According to Van Rensburg et al. (2006:341-344), work overload in the TB programme in the PHC facilities also results from a lack of adequately trained nurses placed in the TB programmes. These untrained nurses continually seek help from or refer patients to those who are trained thereby contributing to their (trained nurses) increased workload.

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In addition, lack of knowledge on what the programme entails fuels the nurses’ fear of being contaminated with TB, therefore discouraging them to work in the TB programme (Athalia et al., 2005:519). However, their fear might not be unfounded because health care workers are at high risk for active TB and latent TB infection, especially health care workers involved in direct contact with patients, such as the nursing professionals (Adenicia et al., 2008:1-2). According to Athalia et al. (2005:519), in New York State 2.3% of TB cases in 1994 and 4.0% in 2002 were health care workers. In South Africa, the emergence of XDR-TB and the evidence that many XDR-TB infections were nosocomial, meaning hospital acquired, leading to a devastating effect on patients and on health workers, especially nurses fuels this fear. Adams et al. (2010:1179) emphasise that the fear is not unfounded. The occurrence of TB in health care workers has been reported to be substantial where ten health care workers with XDR-TB were identified. Majority of health care workers (6 of 10) worked as nursing staff.

However, all these challenges could be better handled by nurses in the TB programme if there are sufficient support systems in place resulting in reassured, well informed and confident nurses who would therefore render quality care. To render quality care in the facility, there are core norms and standards that need to be in place. One of these norms is the rendering of support to the nurses by management with at least a bimonthly visit to ensure that the nurses have adequate resources and to give moral support (Van Rensburg et al., 2004:429-430). This aspect is of utmost importance especially with the current situation in South Africa where staff shortages are rampant. Thus it is critical for the nurses working in programmes such as that of TB to have adequate support as they are faced with more challenges as outlined in the earlier discussion. It would be very difficult to implement a programme successfully if management failed to provide the necessary support such as training and infrastructure thereby leaving the nurses to feel inadequate or unappreciated (Muller, 2002:241).

According to Ngwena et al. (2006:985), support means “to bear all, to corroborate, to encourage or even to comfort”. Support is also defined in terms of physical, emotional and social context. Physical support includes adequate space, well equipped and pleasant work conditions (Douglass, 1992:128) (Searle, 2006: 270). Pera and Van Tonder (2002:185) highlighted that manageable workload also forms part of physical support and it is a legal right (Searle, 2006: 360). Training is also seen as a form of physical support from management and it includes continuing education, in-service education and supervision to ensure that the nurse advances professionally by providing opportunities for promotion (Douglass, 1992:128) (Pera and Van Tonder, 2002:185). Availability of

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policies also forms part of physical support essential for the provision of standardised guidance to nurses (Booysens, 2006:28).

Emotional support would include aspects such as trust among colleagues and management (Douglass, 1992:128) (Sanchez, 2009:97). According to Ellis and Hartley (2004:503), another form of emotional support is the mentoring, guiding, tutoring and coaching of nurses by management which are essential to ensure a sense of belonging and ownership, and prevent infighting due to uncertainty. Social support would be support among nurses, their colleagues, and employers, often expressed in terms of team work whereby each team member’s input is regarded as important and members share responsibility thus lightening the workload (Booysens, 2006:236). Team-building activities at a social level facilitated by management could prove to be a form of social support that could improve relations among colleagues and management. Therefore, lack of support for nurses from management, according to Booysens (2000:364), leads to behaviours such as employee absenteeism and turnover.

Employee absenteeism is defined as time away from work and is viewed by Price and Mueller (in Booysens, 2000:355) as a form of withdrawal from unsatisfactory work conditions which is due to factors such as overworking, physical exhaustion and burnout. The author further defines employee turnover as a constant heavy loss of recruited and qualified nurses which is caused by either avoidable or unavoidable factors. Booysens (2000:355, 272) explains avoidable factors as a failure of an employer to keep employees in the organisation’s service; for example, a hostile, stressful or an environment full of conflict. Consequently, fewer nurses are left to tend to patients, lowering the morale of the remaining nurses, the quality as well as the standards of care which leads to medical and legal risks.

In her study of student’s clinical competencies in the PHC, (Beukes et al., 2010:1) mentioned lack of support to nurses in terms of recognition and incentives as a major problem that impedes quality service delivery. According to (Media Club South Africa, 2011) nurses working in the TB programme are scared for their health and as the result they have been appealing to the government for years for remuneration that takes into account the danger of their job, access to specialized protective mask and for better ventilation in their waiting and consultation areas. It further adds on to say that many people currently working as nurses or training to become nurses are refusing to train as TB nurses because they think it’s too risky and it is not worth it. The health Department is battling to attract and keep nurses in the TB programme because of their fear of

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being infected (Media Club South Africa, 2011), however, if there is adequate support from management this challenge could be avoided.

According to Daiski (as quoted by Cheryl, Woelfe & McCaffrey, 2007:123-131), lack of support for nurses from management makes it a difficult and an uphill battle to advance in proper patient care and to improve the quality of patient care especially in specialised programmes such as in the TB programme. Hence, the need to explore support to nurses working in the TB programmes by management in the Matlosana sub-district is eminent in the quest to improve their well-being and service delivery to the patients infected with TB.

1.2 PROBLEM STATEMENT

TB is a health threat, globally, in Africa, South Africa as well as in North West Province. In the South African context nurses are the main group of health workers who are involved in the treatment and care of TB patients. For them to perform optimally in their duties, they need to receive physical, emotional and social support from management enabling them to find new and innovative ways to give quality care to their patients. According to the primary health care service package on norms and standards (Van Rensburg et al., 2004:429), support is one of the critical aspects that needs to be in place for a programme to succeed. However, there seems to be a gap between the expected support from management by nurses working in the TB programme in health facilities as outlined by the primary health care service package norms and standards and that which is given by management in reality.

As a professional nurse working in a TB programme at the primary health care facility, the researcher has observed that there seems to be a lack of support by management to nurses leading to diminished interest to work in the TB programme consequently impacting on quality service for the TB patient. Therefore, exploring the type and level of support that is given to nurses working in the TB programme by management is important as it will encourage reflection by managers to improve their leadership role, relationship with nurses and consequently quality health care to the TB patients.

1.3 AIM AND OBJECTIVES OF THE STUDY

The aim of this study was to explore the support to nurses working in the TB programme in the primary health care facilities by management in Matlosana sub-district so as to make

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recommendations to improve their work life and consequently improvement in rendering of quality care to the TB patients. To achieve the study aim, the following research questions were asked:

1. What is the support given by management to nurses working in the TB programme at primary health care facilities in the Matlosana sub-district?

2. What recommendations can be made for nursing education, community health practice and further research that will improve the work life of the nurses working in the TB programmes?

1.4 RESEARCH OBJECTIVES

In responding to the above questions, specific objectives were:

1. To explore and describe support to nurses working in the TB programme at primary health care facilities by management in the Matlosana sub-district.

2. To make recommendations for nursing education, community health practice and further research that will improve the work life of the nurses working in the TB programmes.

1.5 SIGNIFICANCE OF THE STUDY

This study will encourage the nurses to highlight the level and type of support they receive from management thereby assisting management to improve, renew or develop support systems that will meet the nurses’ needs. Consequently, this will impact on the job satisfaction and motivation of nurses in the TB programme at the primary health care facility resulting in delivery of sound and effective quality service to the TB patients.

1.6 THEORETICAL ASSUMPTION

Theoretical assumptions are testable and form part of the existing and acceptable theory of a discipline (Botes, 1993:12). The theoretical assumption of this research includes the central theoretical arguments which formed the core of this study as well as conceptual definitions of key concepts applicable to this study.

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1.6.1 Central theoretical argument

The central theoretical argument of this study suggests that there is a generalised lack of support for nurses working in the TB programme at the primary health care facilities in the Matlosana sub-district. Hence the exploration of support to nurses working in the TB programme at primary health care facilities by management will improve the nurses’ work life and enhance delivery of quality nursing care to the TB patients. This knowledge will be useful in the development of recommendations to management to improve, renew or develop support systems that will meet the nurses’ needs thereby enhancing quality of care.

1.6.2 Conceptual definitions

The following concepts are key in this study and are defined as follows:

1.6.2.1 Support

According to the Ngwena et al. (2006:985), support means to “bear all, to corroborate, to encourage, or even, to comfort”. Support is also defined in terms of physical, emotional and social context. Physical support includes adequate, well equipped space and pleasant work conditions, emotional support include mentoring, and guiding, tutoring and coaching whereas social support is support among nurses themselves and their employers; for example, team work and team building exercises (Douglass, 1992:128).

In this study, physical support means TB nurses working in a well-equipped, pleasant working condition with adequate space, financial means, technology and manpower (Booysens, 2000:604). Emotional support means mentoring, guiding, tutoring, coaching and counselling while social support mean facilitation of team work by managers in the workplace.

1.6.2.2 Tuberculosis (TB)

It is an infectious disease caused by a micro-organism, the bacilli called Mycobacterium tuberculosis which usually enters the body by inhalation through the lungs. It spreads from the initial location in the lungs to other parts of the body via the blood stream, the lymphatic system, via the airway or by direct extension to other organs (Ait-Khaled et al., 2010:2). Depending on the

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individual's immune system; the bacilli may become dormant until activated when the immune system is compromised.

1.6.2.3 Tuberculosis Programme

Is a programme designed to improve case finding by detecting TB cases; decreasing mortality and morbidity. Further to this, is to prevent and treat TB even amid HIV positive patients and finally to decrease the occurrence of multidrug-resistant TB (MDR-TB) (Department of Health, 2004:7).

1.6.2.4 Nurse

The Nursing Act (33 of 2005) defines a nurse as an individual who has successfully completed a course of study prescribed by the council and is licensed to practice as a nurse practitioner and who, in the opinion of the council, has knowledge and skills sufficient as prescribed by the regulations to be licensed to practice as a nurse practitioner under this Act. In addition, the Nursing Act (33 of 2005) defines a professional nurse as a person who is registered as a nurse under section 31 of this act.

According to section 31 of the nursing Act (33 of 2005) a professional nurse is a person who is qualified and competent to independently practise comprehensive nursing in the manner and to the level prescribed and who is capable of assuming responsibilities and accountability for such practice. On the other hand a staff nurse is a person educated to practise basic nursing in the manner and to the level prescribed and is registered as such in terms of section 31 while an auxiliary nurse is a person educated to provide elementary nursing care in the manner and to the level prescribe and is registered as such in terms of section 31.

In this study, nurses will mean those nurses working in the TB programme in the primary health care facilities at Matlosana sub-district. These individuals will include professional nurses, staff nurses and auxiliary nurse registered with the South African Nursing Council (SANC).

1.6.2.5 Management

Management, according to Shead (2009) is the art of conducting, directing and leading. It characterises the process of leading and directing all or part of an organisation, often a business, through the deployment and manipulation of human, financial, material, intellectual or intangible

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resources. In this study, management are those individuals who perform conduct, direct, supervise and lead nurses working in the TB programme. These individuals include both the facility managers and TB coordinators in the Matlosana sub-district.

1.6.2.6 Facility manager

Facility managers are professionals who are responsible for integrating people with their physical environment, and manage both people and their environment. They work both as the operational manager and as the compliance officer where they manage people, productivity and the costs involved. Facility manager coordinates policies and operations with industry standards, practices and with regulatory mandates (Gustin, 2005: ix).

1.6.2.7 TB co-ordinator

According to WHO (2005b: 1) the person (or team) responsible for TB control at the district level is called the District TB Coordinator. The District TB Coordinator is usually a physician or a nurse. He or she works at the district health office and the job of District TB Coordinator is primarily administrative and managerial. Although the District TB Coordinator must be thoroughly familiar with clinical guidelines of the national TB control programme, he or she is primarily responsible for enabling and monitoring the implementation of these guidelines, rather than actually treating patients. In the South African context district TB coordinator functions at sub-district level therefore called sub district TB co-ordinator.

1.6.2.8

Primary Health Care Facility

Friedman and Padarath (2008), defines a clinic as a permanently equipped facility at which a package of Primary Health Care (PHC) services are provided. The operating times are a minimum of 8 hours per day and minimum of 4 days per week. For the purpose of this study, a clinic will be referred to as a primary health care facility due to the adopted national health care approach which is PHC driven.

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1.7 RESEARCH DESIGN AND METHOD

In this chapter, the research design and method is discussed briefly and the more detailed discussion will follow in Chapter 2.

1.7.1 Research design

A qualitative research design which is exploratory, descriptive and contextual in nature was used to explore and describe the support for nurses by management in the TB programme at primary health care facilities in Matlosana sub-district (Burns & Grove, 2005:55). This has led to recommendations for the improvement of the nurses work life intended for improvement in rendering of quality care to the TB patients as the final outcome. The research was conducted within the context of primary health care facilities within the Matlosana sub-district in the North-West Province.

1.7.1.1 Qualitative research

Creswell (2003:179) describes qualitative research as an inquiry process of understanding based on distinct methodological traditions of inquiry that explore a social or human problem. Denzin and Lincoln (2000:3) claim that qualitative research involves an interpretive and naturalistic approach: “This means that qualitative researchers study things in their natural settings, attempting to make sense of, or to interpret, phenomena in terms of the meanings people bring to them” .Therefore for the purpose of this study a qualitative research was chosen to explore and describe the support for nurses by management in the TB programme at primary health care facilities that is in their natural setting.

1.7.1.2 Exploratory design

According to De Vos et al. (2002:109) exploratory research design is a design that is conducted to gain insight into a situation, phenomenon, community or individual. These authors furthermore added that the need for such a study could arise from a lack of basic information on a new area of interest or in order to become acquainted with a situation so as to formulate a problem or develop a hypothesis. Exploration enables the researcher to gain a richer understanding of, and insight into, a comparatively new phenomenon, for which little or no research has been done (McMillan & Schumacher, 2006:318).

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For the purpose of this study support for nurses especially in a specific programme is being viewed as a new concept in health care, because many studies done on support focuses mainly on patients need for support and not the nurses. Therefore the researcher aims to gain knowledge on the support for nurses by management in the TB programme at primary health care facilities. Within the context of this research, exploration was used to gain insight into the views of participants (nurses) regarding support from management

1.7.1.3 Descriptive design

According to De Vos et al. (2002:109) a descriptive design is a design that is aimed at providing a complete and accurate picture of a situation. It emphases on “how” and “why” questions seeking to describe events or experiences after observation (Babbie, 2004:89). In this study the researcher chose this design so as to be able to clearly describe the support for nurses by management in the TB programme at primary health care facilities in Matlosana sub-district.

1.7.1.4 Contextual design

A context is according to Strauss and Corbin (1990:96) a particular set of conditions within which the action is taking place. It is characterised by an ‘explicit set of properties pertaining to a phenomenon (Strauss & Corbin 1990:101). Holloway and Wheeler (1998:182) state that contextual research aims to describe the phenomenon in the situation in which it normally occurs. The phenomenon of interest is explored in the immediate environment and physical location of the people studied. Therefore the researcher intended to explore the phenomenon under the context of the primary health care facilities in Matlosana sub-district. The idea is not to generalise the findings but interpret them in this context.

1.7.2 Research method

The research method included a brief exposition of the population, sampling, study context, data collection, data analysis, literature control, ethics, and rigour.

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1.7.2.1 Population

Population included all the categories of nurses working in the TB programme that is professional nurses, staff nurses and auxillary nurses in all the 16 Matlosana sub-district primary health care facilities including three health care centres. They must have been working in the TB programme for duration of one year irrespective of their race, culture, age and language.

1.7.2.2 Sampling

Brink (2006:123) defines a sample as a part or fraction of a whole, or a subset of a larger set, selected by the researcher to participate in the study, while Burns and Grove (2005:352) explain sampling as a process that involves selecting a group of people, events, behaviours, or other elements with which to conduct the study. Sampling included the sampling technique used in the study and the sample size.

 Sampling technique

Sampling technique is a strategy suitable for a particular research study to acquire the most appropriate participants. Non probability purposive sampling technique was used which implies that the researcher selected nurses to be sampled based on their knowledge and professional judgment as a more representative sample that can bring more accurate results (Castillo, 2009). The selected participants complied with the set criteria and were willing to participate.

 Sample size

According to Burns and Grove (2005:358-359), sample size is the number of participants, determined by the depth of information needed to gain insight into the phenomenon. For the purpose of this study the sampling to redundancy technique was chosen, which involves not defining the one’s sample size in advance but interviewing more and more people until same themes and issues came up over and over again (Blanche et al., 2007: 49). Hence sample size was determined by data saturation meaning that the researcher did not know in advance how many participants were needed, but she accumulated samples continuously until no new information was acquired from the participants.

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1.7.2.3 Study context

Matlosana sub-district consists of four towns namely Klerksdorp, Stilfontein, Orkney and Hartbeesfontein. Klerksdorp is urban in character while Stilfontein, Orkney and Hartbeesfontein are all semi-urban in character. Each town comprise of 4 PHC facilities of which 3 are 8 hour clinics and the fourth PHC facility is a community health centres which function 24 hours. All the PHC facilities are managed by facility managers who foresee the smooth running of each facility. Each facility has its own TB programme headed by either a professional nurse or an auxiliary nurse or by both. All in all there were 13 proffessional nurses by training heading the TB programme in all the 16 PHC Facilities, 3 auxillary nurses and 2 health promoters who did not meet the set criteria and were not interviewed. All the TB programme leaders have undergone in-service training for coordinating this programme.

1.7.2.4 Data collection

This section comprised a description of the role of the researcher, the physical environment and method of data collection.

 Role of the researcher

The researcher submitted a research proposal and a drafted consent form (ADDENDUM F) to the research ethical committee of the North-West University (NWU) at the Potchefstroom campus, and the North West Provincial (ADDENDUM A), district and sub district management for approval of conducting the study (ADDENDUM B). Upon receiving approval (ADDENDUM C & D) from both the provincial and sub district the researcher contacted the facility managers telephonically to arrange for visits to their facilities. The potential participants were then contacted to gain their cooperation and to explain the purpose of the study. A full exposition of the process will be given in the following chapter.

 Physical environment

Burns and Grove (2005:359) explain the physical setting as an uncontrolled, real-life situation, or environment that facilitates capturing of in-depth information.

For the purpose of this study, the researcher did not manipulate or change the environment for the study; instead, interviews were held at a place which was chosen and convenient for the participants so as to ensure a private and non-intimidating atmosphere without

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interference. The researcher realised that in the Primary Health Care (PHC) surroundings confidentiality might not be possible because nurses may be afraid to express themselves for fear of being intimidated by their managers and colleagues. Hence, the interview venue was arranged in such a way that it was away from the activities in the PHC in a well-ventilated, clean setting and with the right temperature so as to make participants feel comfortable and at ease, thus encouraging free participation.

 Method of data collection

According to Blanche, Durrheim and Painter (2007:287), in qualitative studies the aim of the researchers is to make sense of feelings, experiences, social situations, or phenomena as they occur in the real world. To attain that in this study, one-on-one interviews were conducted with nurses working in the TB programme at primary health care facilities in the Matlosana sub-district. The interviews were semi-structured (Blanche et al., 2007:287) and an interview schedule (see addendum J) which was developed in advance was used. A full exposition of the process will be given in chapter 2.

1.7.2.5 Data analysis

According to (Brink et al., 2006:184), data analysis in qualitative research is the examination of words where the researcher spent hours reflecting on the possible meanings and relationships of the words and becomes deeply immersed in the words. Furthermore qualitative data analysis is a systematic process of selecting, categorizing, comparing, synthesizing and interpreting data to provide explanations of the single phenomenon of interest (White, 2003:82).In this study, the data captured on the digital voice recorder was subject to transcription and analysed according to the process of open coding. This included coding for themes and categories as highlighted by (Brink et al., 2006:185). In addition making memos about the context of and variations in the phenomenon under study, verifying the selected themes through reflection on the data and discussions with other researchers and experts in the field was undertaken. To assist the researcher in effectively executing the coding process Tesch’s generic steps as cited by Cresswell (2003: 190) were applied. This will be discussed in more detail in Chapter Two of the study. Lastly the use of a co-coder was adopted to compare and identify similarities and differences of the emerging themes so as to reach consensus regarding the categories and sub-categories thus allowing for conclusion to be drawn.

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1.7.2.6 Literature control

According to De Vos et al. (2005:123), a literature review is aimed at contributing towards a clear understanding of the problem that has been identified. Hence, for the purpose of this study the researcher used literature control to compare, and verify the research findings obtained in the current study with relevant literature and existing research findings to determine similarities and differences on support to nurses in the TB programme at primary health care facilities by management.

1.8 TRUSTWORTHINESS

According to Krefting (1991:215), for a research to be trustworthy it should be conducted in a manner that will ensure accuracy in presenting the lived experiences as reported by the participants. Trustworthiness is measured through the use of the following criterion truth value, applicability, consistency and neutrality. In this section a brief discussion on trustworthiness will follow with a detailed description of how this factor was ensured described in chapter 2.

1.8.1 Truth value

Krefting (1991:215) termed truth value as credibility, and he further stated that credibility is aimed at establishing how confident the researcher is with the truth of the findings based on the research design, participants and context. In this study, truth value in the form of credibility was obtained by the use of strategies such as peer evaluation and reflexive analysis which was done by the co-coder through the independent analysis of raw data given to her.

1.8.2 Applicability

Applicability is termed as transferability by Krefting (1991:215). Transferability refers to the degree to which the findings can be applied to other contexts and settings. In this study, the findings that were generated from the Matlosana sub-district could not be generalised to a larger population, according to (Krefting, 1991:216). This is due to the fact that study settings differ and the purpose of this study was to describe specific experiences in that context and not to generalise. However to ensure applicability, strategies such as nominated sample, comparisons of sample to demographic data, time sample and dense description are used (Krefting, 1991:216). In this study the researcher provided a dense description of methods and procedures that were followed and clearly explained

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the context in the research report so that consumers and other researchers can evaluate the applicability of data to other contexts.

1.8.3 Consistency

Consistency is defined in terms of dependability which is concerned with whether the findings would be consistent if the interviews were replicated with the same participants or in a similar context (Krefting, 1991:216). Therefore, consistency is achieved when dependability has been achieved. According to Polit, Beck and Hungler (2001:312), dependability of qualitative data refers to the stability of data over time and over conditions. Strategies used to establish dependability include dependability audit, dense description, stepwise replication, triangulation, peer examination and code-recode (Polit et al., 2001:312). In this study, consistency was established by means of dense description which clearly and comprehensively described the exact methods of data gathered. An inquiry audit where relevant supporting documents where scrutinised by an external reviewer to make interpretation and conclusion was also undertaken. The co-coder acted as the external reviewer.

1.8.4 Neutrality

Guba and Lincoln (in Krefting, 1991:216) refer to neutrality as the degree to which the findings are a function solely of the informants and conditions of the research and not of other biases, motivations, and perspectives. He further suggested conformability as the criteria to measure neutrality. Conformability is, according to Sandelowski, the freedom from bias in the research procedures and results (Krefting, 1991:216). Strategies such as conformability audit, triangulation and reflexivity are used to ensure conformability (Krefting, 1991:216). For the purpose of this study, conformability audit and reflexivity were utilised where by reflexivity, that is, the researcher’s reflection of her own biases, was done before initiating interviews. This was accomplished by jotting down her own views, perceptions as well as her experience on the topic of the study in a diary. Also, raw data, that is, the audio recordings including field notes, and the interview schedules were made available to the co-coder to allow the co-coder to come to conclusions about the data (Krefting, 1991:221).

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1.9 ETHICAL ASPECTS

Sound ethically grounded research is strictly based upon principles and standards of ethical conduct. Pera and Van Tonder (2002:21) view those ethical principles as action guides to moral thinking and decision-making in a particular situation. Brink et al. (2006:345-349) emphasize that conducting research in an ethical manner means that the researcher must carry out the research competently and most importantly consider the consequences of the research for the society, specifically the participants. Researchers have to be aware of the rights of human subjects and other ethical issues when planning a research project that deals with human subjects. The following are the relevant ethical principles and procedures adhered to in this study:

1.9.1 Review by ethical committee

According to Brink et al. (2006:41), ethical committees review proposed research, examine and monitor ethical standards of ongoing research and they may give or refuse permission for the researcher to carry out the study or may recommend changes to the research proposal if they are not satisfied (Brink et al., 2006:30). Therefore, for the current study, the researcher submitted the research proposal to the ethical committee of the North-West University at the Potchefstroom campus, the North West Department of Health and to the Matlosana sub district for review and for permission to undertake the research. A full proposal was submitted clearly indicating the purpose of the study, the research design and the ethical considerations that the researcher adhered to. The interview schedule and the consent form were added so that the committees could evaluate its acceptability and the ethical stance.

1.9.2 Fundamental ethical principles

According to Brink et al. (2006:31), there are three fundamental ethical principles that are concerned with the protection of the right of human subjects. These principles are principles of respect for person which involves self-determination and protection of vulnerable groups, the principle of beneficence where the researcher has to secure participants’ right to protection from discomfort and harm as well as the principle of justice which includes the right to fair selection and treatment and the right to privacy. The researcher adhered to these principles in the following manner:

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Burns and Grove (2005:90) assert that the principle of beneficence that states that one should do well and above all, do no harm should be clearly stated in research. The right to self-determination expresses respect for the unconditional worth of an individual and respect for individual thought and action (Pera & Van Tonder, 2002:23). In this study, during the recruitment phase, individual briefing sessions were done whereby each participant was informed on the purpose of the research, the objectives of the research set out and the expected risks and benefits outlined. The participants were informed that they can withdraw from the study at any instance without fear of penalty.

 The right to full disclosure

The participants were informed about the following aspects (Wilson, 1993:250) which the researcher adhered to:

o The nature, duration and purpose of the study;

o The methods, procedures and processes by which data would be collected; o Any inconveniences or discomfort that could result;

o The right to refuse to participate or to withdraw at any stage without being discriminated against; and

o The identities of the researcher and how to contact her.

The researcher included all the above mentioned criteria in the consent form and she verbally explained it to the participants.

 The right to self-determination

The right to self-determination is noted by a lack of constraints from the participants, coercion or undue influence of any kind (Burns & Grove, 2005:200).The right to self-determination expresses respect for the unconditional worth of an individual and respect for individual thought and action (Pera & Van Tonder, 2002:22). The participants were given the latitude to ask the researchers questions for the purpose of clarity and decision-making on whether or not to participate.

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 The right to privacy, anonymity and confidentiality

The participants in this study were given the right to determine the time as well as the circumstances under which private and personal information will be shared or withheld from others (Burns & Grove, 2005:186). The information that the participants divulged during the interview was not discussed with persons not involved in this study, including their employers. The interviews were conducted at the venues chosen by the participants to help to calm, comfort, relax and to ensure privacy. Participants were informed about the use of an audio recording device to record the conversation and the taking of field notes. These were then safely stored with no one having access but the researcher.

Anonymity refers to the fact that no links can be made between the participant and the information reported. Only the researcher knew the identity of the participants and this was treated with confidentiality (Burns & Grove, 2005:186). In this study, anonymity was maintained as maximally as it was possible although the participants knew each other and were aware of individuals who participated. However, information could not be linked to a particular participant as names did not appear in any documentation, and codes were used to refer to participants. Data on the digital voice recorder was deleted after being transcribed; therefore, names mentioned during the interview could not be known or identified.

 Scientific honesty

To maintain scientific honesty the researcher intend sharing the results with the scientific community in a respectful manner using an accredited journal. In adhering to this aspect, the researcher will ensure that all the information reported will be accurate and no data will be falsified. The researcher also acknowledged other authors whose literatures were used to enrich this study, so as to ensure that no plagiarism was committed. The results will also be shared with management and with the participants in a form of presentations and the submission of the dissertation to management.

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1.10 CHAPTER OUTLINE

Chapters were divided as follows:

 Chapter one: Overview of the study  Chapter two: Research methodology

 Chapter three: Research findings and literature control; and

 Chapter four: Conclusions, limitations and recommendations for nursing education, nursing research and community health practice.

1.11 CONCLUSION

In this chapter, an overview of the study was given, which was composed of an introduction, problem statement, research questions, aims and objectives of the study, significance of the study, theoretical assumption, brief orientation to the research methodology, trustworthiness and ethical aspects. The following chapter entails the full exposition of the research design, research method, and ethical issues related to the respect for the participants, as well as trustworthiness which is related to the quality of the research.

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CHAPTER 2

RESEARCH METHODOLOGY

2.1 INTRODUCTION

In the previous chapter an overview of the study was given, which was composed of an introduction, problem statement, research questions, aims and objectives of the study, significance of the study, theoretical assumption, and a brief orientation to the research methodology as well as ethical aspects. This chapter entails the full exposition of the research design, research method, and ethical issues related to the respect for the participants, as well as trustworthiness which is related to the quality of the research.

2.2 RESEARCH DESIGN AND METHOD

2.2.1 Research Design

In this study, a qualitative research method using exploratory, descriptive and contextual design was used.

2.2.1.1 Qualitative research

Qualitative research is, according to Burns and Grove (2005:52), a systematic, subjective method used to describe life experiences and give them meaning. The authors further state that the qualitative research method is a way of gaining insight by exploring the depth, richness and complexities found in the phenomena. Brink et al. (2006:113-121), see it as a method used by researchers who wish to explore the meaning, or describe and promote understanding of human experiences or an unfamiliar phenomenon that would be extremely difficult to quantify. Therefore, this method was applicable in this study as the objectives were to:

To explore and describe support to nurses working in the TB programme at primary health care facilities by management in the Matlosana sub-district.